Provider First Line Business Practice Location Address:
3304 TENNESSEE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66067-8205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-210-1929
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2026